World Health Organization Regional Office for the Western Pacific Drug-resistant tuberculosis in the WHO Western Pacific Region Tauhid Islam Stop TB and Leprosy Elimination World Health Organization Regional Office for the Western Pacific NINTH TECHNICAL ADVISORY GROUP (TAG) AND NATIONAL TB PROGRAMME MANAGERS MEETING FOR TB CONTROL WORLD HEALTH ORGANIZATION REGIONAL OFFICE FOR THE WESTERN PACIFIC 9-12 December 2014, Manila, Philippines

World Health Organization Regional Office for the Western Pacific MDR-TB patients speak Courtesy: MDR-TB working group, Stop TB Partnership

World Health Organization Regional Office for the Western Pacific Content highlights Coverage of DRS Estimated MDR-TB burden Burden over time DST coverage: FLD &SLD Notifications and enrolment Treatment outcomes Financing Cascade of PMDT Way forward - Group work

World Health Organization Regional Office for the Western Pacific Data source Data source: Global TB database Acknowledgements: All countries of the Region who submitted data and Tom Hiatt Nobuyuki Nishikiori Cornelia Hennig Matteo Zignol Anna Dean

World Health Organization Regional Office for the Western Pacific Coverage of DRS Drug resistance data available from 25 of the 36 countries and areas –Routine surveillance - 19 –Periodic surveys - 6 National DRS data - 5 out of 7 priority countries At least two national representative survey data points - Cambodia, Mongolia, Philippines and Viet Nam 2 countries with pending DRS data: Papua New Guinea and Lao People’s Democratic Republic Malaysia's 1997 data originated from non-representative geographical areas

World Health Organization Regional Office for the Western Pacific Estimated MDR-TB MDR-TB among new cases MDR-TB among previously treated TB cases Total MDR-TB cases CountryData type and yearn % N % n Australia Surveillance (2013) 16(9–27) 2(1–4) 1(0–7) 4(< 1–21) 17(8–26) Cambodia Survey (2007) 320(160–580) 1(< 1–3) 180(68–370) 11(4–22) 510(270–740) China Survey (2007) (35 000–55 000) 6(5–7) 9 200(7 800–11 000) 26(22–30) (48 000–61 000) Hong Kong (China) Surveillance (2012) 34(21–52) < 1(< 1–1) 9(3–20) 3(< 1–6) 43(26–59) Macao (China) Surveillance (2013) 7(2–16) 2(< 1–5) 4(1–10) 12(2–30) 11(4–18) Japan Surveillance (2002) 110(63–160) < 1(< 1–1) 100(72–130) 10(7–13) 200(150–260) Lao People’s Democratic Republic Model† 160(96–230) 5(3–6) 65(56–75) 24(20–27) 220(160–290) Malaysia Survey (1997) 19(0–120) < 1(0–< 1) 0(0–340) 0(0–17) 19(0–57) Mongolia New: Survey (2007) Previously treated TB : surveillance (2013) 33(16–59) 1(< 1–3) 210(180–240) 34(29–38) 240(210–280) New Zealand Surveillance (2012) 1(0–5) < 1(< 1–3) 2(0–5) 17(2–48) 3(0–6) Papua New Guinea Model 560(340–800) 5(3–6) 570(480–650) 24(20–27) 1 100(890–1 400) Philippines Survey (2012) 4 400(3 100–6 000) 2(1–3) 4 100(3 000–5 500) 21(16–29) 8 500(6 900–10 000) Republic of Korea Surveillance (2004) 780(600–980) 3(2–3) 1 200(850–1 600) 14(10–19) 1 900(1 600–2 300) Singapore Surveillance (2013) 17(8–30) < 1(< 1–2) 3(0–12) 3(< 1–9) 20(9–31) Viet NamSurvey (2012) (1 900–4 100) 4(3–5) 2 100(1 500–2 600) 23(17–30) 5 100(4 100–6 100) Western Pacific Region (31 000–75 000) 4(3–6) (15 000–21 000) 22(18–26) (47 000–94 000)

World Health Organization Regional Office for the Western Pacific Estimated MDR-TB

World Health Organization Regional Office for the Western Pacific Estimated MDR-TB Intercept 0.08%, coefficient 3.1%, F-statistics 3.84, p=0.123

World Health Organization Regional Office for the Western Pacific Trends in drug resistance

World Health Organization Regional Office for the Western Pacific Trends in drug resistance

World Health Organization Regional Office for the Western Pacific Trends in drug resistance

World Health Organization Regional Office for the Western Pacific DST coverage Notified cases with DST resultsCases confirmed by Xpert among MDR-TB and RR-TB * New Ret. TotalNew Ret. Total n% n% n%n% N% n% Cambodia–– –– –––– –– –– China Lao People’s Democratic Republic 11< – Malaysia Mongolia Papua New Guinea–– –– 93< 1–– –– 3372 Philippines25< –– –– –– Viet Nam353< Western Pacific Region

World Health Organization Regional Office for the Western Pacific DST coverage Among patients tested in 2013 – 8% were resistant to isoniazid only –2% were resistant to rifampicin only –11% were resistant to both The Xpert MTB/RIF test was used to identify 17% of MDR-TB patients –highest for Viet Nam at 81%

World Health Organization Regional Office for the Western Pacific DST coverage

World Health Organization Regional Office for the Western Pacific Notifications and enrolment EstimatedNotified % notified among estimated Enrolled on treatment New Ret. TotalNew Ret. Total a New Ret. Totaln % among detected Cambodia – – 121– – China Lao People’s Democratic Republic Malaysia NA Mongolia Papua New Guinea – – 119– – Philippines < Viet Nam Western Pacific Region

World Health Organization Regional Office for the Western Pacific Notifications and enrolment

World Health Organization Regional Office for the Western Pacific Treatment outcome

World Health Organization Regional Office for the Western Pacific Second line DST & XDR-TB 2nd-line DSTResistance to FQ Resistance to 2nd-line injectible XDR-TB number % of enrolled number % of tested number % of tested number % of tested Australia Hong Kong Special Administrative Region (China) Macao Special Administrative Region (China) Lao People’s Democratic Republic Malaysia < 1 Mongolia New Zealand Papua New Guinea –– Philippines < 1 Republic of Korea Singapore Viet Nam Western Pacific Region

World Health Organization Regional Office for the Western Pacific Financing for MDR-TB

World Health Organization Regional Office for the Western Pacific AT A GLANCE % Patients of MDR-TB estimated among reported TB patients by national TB programmes in Western Pacific Region in % of the estimated patients with MDR-TB ( out of ) were detected and reported in % detected MDR-TB were started on second –line treatment for MDR-TB in 2013, leaving many patients untreated Of MDR-TB patients of 2011 cohort had a successful treatment outcome

World Health Organization Regional Office for the Western Pacific Cascade of patient centred PMDT (1) step-wise increase of the proportion of TB patients who receive drug susceptibility testing (DST) (2) all diagnosed patients are promptly notified and enrolled in treatment (3) all enrolled patients complete their treatment with effective patient-centred support.

World Health Organization Regional Office for the Western Pacific Major issues Low DST coverage Laboratory capacity Slow roll out of rapid diagnostic Screening policy and practise Human and financial resource Burden of MDR-TB among new Mis- alignment: Notification- enrolment Poor treatment outcome/high loss to follow up Lack of access Lack of communicatio n Non- availability of drugs Lack of psycho social support Lack of enabling environment

World Health Organization Regional Office for the Western Pacific PRIORITY ACTIONS

A public health crisis Even if most TB patients in the world are not drug-resistant (5% of total TB burden), the burden of MDR-TB in the world poses a formidable challenge to the prospect of controlling TB Drug susceptible strain may be replaced by drug resistant strain Overall treatment success rate less than 50% complicated long treatment catastrophic expenditure ( times costly than drug susceptible TB) huge burden on existing human resource and technical capacity

World Health Organization Regional Office for the Western Pacific ‘How to’ plan Guiding questions: –How to improve cascade of care in each country by the next 2 years? Expected outcome –Group or country specific presentation

World Health Organization Regional Office for the Western Pacific ‘How to’ plan Group work: Group 1: Philippines; Viet Nam, PNG Upper lounge Facilitators: Lee Reichman, Chen-Yuan Chiang) –Group 2: Cambodia, Lao PDR, Mongolia Room 212 Facilitators: Jacques van den Broek, Takashi Yoshiama –Group 3: China, Malaysia Room 210 Facilitators: Wing-Wai Yew, Richard Lumb

World Health Organization Regional Office for the Western Pacific Courtesy: MSF access campaign – test me – treat me “We have to make this people’s fight. Each one has a name and a family. They are not just numbers.”